To the Editor: Violent crime pervades South Africa, with murder, rape and serious assault directly affecting around 1 in 50 people per annum.1 Approximately 21% of the South African population resides in KwaZulu-Natal province, which has some of the country's highest rates of poverty and violent crime.2 Law enforcement in such areas is challenging and, as a result, some 40% of households are dissatisfied by the level of policing in their communities.3

Unpunished criminals and an inadequate justice system have led communities to resort to their own form of retribution.4 Severe beatings, termed community assault (CA), are administered by members of the local community when alleged criminals are caught. This practice is intended to inflict serious injury rather than to kill, and to serve as punishment upon the alleged perpetrator and as a warning to potential offenders. This alternative to the conventional justice system has been applied in 4 - 6% of all crimes committed in South Africa.3

We highlight the inhuman practices that occur as a result of the failing South African criminal justice system, and we further quantify the range of serious injuries that are sustained secondarily to CA and reinforce the importance of early medical intervention.

Materials and methods

Data were prospectively collected on all CA patients presenting at Ngwelezane Hospital (NGW), a tertiary referral centre for northern KwaZulu-Natal, between October 2006 and January 2007. All patients were managed in accordance with advanced trauma life support (ATLS) principles. Details regarding the mechanism and time of assault were collected. Routine blood investigations, chest radiographs and urinalysis were carried out as standard. Further investigations were performed as clinically indicated. Patient progress and any necessary interventions were noted. The primary end-point of the study was the injuries received. Secondary end-points included time from injury to arrival at NGW and final patient outcome.

Results

Data on 19 consecutive patients were collected (Fig. 1); 94.7% were males aged 14 - 48 years (mean 27.1 years); 9 (47.4%) were referrals from rural hospitals, and 10 (52.6%) presented directly to our unit. The average time from injury to presentation at NGW was 4.8 hours (range 0.5 -13) for those presenting directly, and 49.1 hours (10 -168) for those referred from smaller rural hospitals.

Significant morbidity was experienced by 16 (84.2%) patients, with 3 (15.9%) subsequent deaths; 7 (36.8%) developed renal dysfunction secondary to rhabdomyolysis, 3 (42.9%) of these progressed to acute renal failure requiring haemodialysis, with 1 resulting mortality. All patients in this subgroup were referrals from other hospitals and arrived at NGW 13 or more hours after assault. All patients with renal impairment presenting to NGW within 13 hours of assault resolved with conservative treatment. Four (22.2%) patients required exploratory laparotomy; 3 had a perforated jejunum (15.8%). Of these, 2 presenting at 10 and 71 hours survived, 1 presenting at 120 hours died of multi-organ failure. The fourth patient required a splenectomy for an unstable grade III splenic injury.

Discussion

This series demonstrates the significant morbidity and mortality associated with CA, a mechanism of injury that should not be underestimated. We observed that patients often had been severely beaten with implements such as a sjambok - a robust whip traditionally made from hippopotamus or rhinoceros hide.

The accused often hide in the bush for many hours after the assault, and also lack the community support necessary to allow them to seek medical attention. Failure to identify serious injuries in small rural hospitals, and the time required for subsequent inter-hospital transfer to an appropriate facility, may further delay appropriate life-saving intervention.

Any delay in the initiation of aggressive fluid resuscitation in patients with rhabdomyolysis leads to an increased incidence of acute renal failure (ARF) and a rise in mortality.5 ARF was common in our patients and reflected the severity of the beating. A longer time from injury to presentation at NGW resulted in a corresponding increase of ARF and subsequent requirement for haemodialysis.

Jejunal perforations were common in our series, compared with other reports.6 Although numbers were small, we found a delay in laparotomy correlated with a longer hospital stay and increased mortality, in keeping with the literature.7

In a country with inadequate policing and an overloaded judicial system, communities find it more expedient to take criminal matters into their own hands. Until such rural populations feel suitably supported, they will continue to implement this flawed and dubious form of retribution. Medical practitioners must recognise CA as being life-threatening and treat patients aggressively. Given the complex patterns of the injuries observed, patients should be managed in a setting with the appropriate facilities. For this reason, we suggest that rural hospitals should have a low threshold for transferring patients to regional centres.